Sohonos — Blue Cross Blue Shield of Texas

Initial criteria

• 1. The member resides in Ohio AND
• 2. The plan is Fully Insured or HIM Shop (SG) AND BOTH of the following:
• A. The patient does NOT have any FDA labeled contraindications to the requested agent AND
• B. ONE of the following:
• 1. The patient has another FDA labeled indication for the requested agent and route of administration OR
• 2. The patient has another indication that is supported in compendia for the requested agent and route of administration OR
• 3. The prescriber has submitted TWO articles from major peer-reviewed professional medical journals supporting the proposed use(s) as generally safe and effective (Accepted study designs include randomized, double blind, placebo controlled clinical trials; case studies not acceptable).
• Non-oncology compendia allowed: DrugDex level 1, 2A or 2B, AHFS-DI (narrative text must be supportive).
• Oncology compendia allowed: NCCN 1 or 2A, AHFS-DI (narrative text must be supportive), DrugDex level 1, 2A, or 2B, Clinical Pharmacology (narrative text must be supportive), LexiDrugs evidence level A, peer-reviewed medical literature.

Reauthorization criteria

• 1. The patient has been previously approved for the requested agent through the plan’s Prior Authorization process AND
• 2. The patient has had clinical benefit with the requested agent AND
• 3. The prescriber is a specialist in the area of the patient’s diagnosis (e.g., endocrinologist, geneticist, rheumatologist) or the prescriber has consulted with a specialist in the area of the patient’s diagnosis AND
• 4. The patient does NOT have any FDA labeled contraindications to the requested agent.

Approval duration

12 months